Hummingbird Ayahuasca Retreat Center
Please print and complete this form and send it to the address below. We also need a copy of
your passport page which has your photograph on it so we can recognise you at our collection
You may also complete this form on your computer and email it, and a scan of your passport
page as attachments to email@example.com. Receipt of this completed form from
your email constitutes agreement to all terms and conditions found at the end of this form.
Your 50% deposit or payment in full should be sent at the same time by bank transfer or
Western Union. Bank details are below, or to use Western Union simply send payment to any
Western Union Office in Iquitos Peru, in the name of “Gina Ysabel Mosquera Vega de Davis”
(yes, all that!) and email the transfer number (mtcn) to firstname.lastname@example.org.
If you send a deposit, full payment will be due on or before the first day of your stay. You may
pay your balance in cash when you arrive in $US. Please bring only new bills, with no tears or
writing on them. Old, damaged or crumpled bills will not be accepted in Peru.
The Hummingbird Retreat Center, PO Box 197, Serpost, Iquitos, Peru
Telephone: 0051 65965345696
OUR BANK ACCOUNT FOR PAYMENT TRANSFERS
Bank Name: Scotia Bank
Bank Address: Calle Prospero 278, Iquitos, Peru
Bank Branch: Iquitos
Recipient Name: James Drake Davis
Recipient Email: email@example.com
Account Number: 009 754 217540001963 32
Swift Code: BSUDPEPL
When sending a wire transfer to our bank, please ensure you send enough to cover all fees you
incur. If you are at the bank, you may state you want to ensure we receive the full amount.
Thank you for your assistance in this.
HOW TO FILL OUT THIS FORM
To fill out this form on your computer, simply press the tab key to move through the form
fields. This will highlight the text ‘edit this text’ and you can begin typing. To put an X in a
check box, press the space key when it is selected. Press the enter key if you want to start a
new paragraph. To print this form to fill out by hand, please first delete ‘edit this text’ in each
form field and press the enter key to add the space required.
Your Name: edit this text
Your Address: edit this text
Your Zip/Postcode: edit this text
Your Phone number: edit this text
Your Email: edit this text
Your Age (N.B. The minimum age for participants is 18): edit this text
□ I wish to join the program below and enclose a payment of $ . This is my:
50% Deposit or
Payment in full
This is the program I am joining:
12-day retreat ($1500)
Individual healing retreat/plant diet – $1800 for 14 days, $3200 for 1month, $6000 for 2
Date program begins: edit this text
MEDICAL ADVICE AND PRECAUTIONS
Ayahuasca (Banisteriopsis caapi) contains monoamine oxidase inhibitors (MAOIs) in the form
of harmine and harmaline. We suggest therefore that you consult your medical advisor if you are
taking medications which may affect your serotonin levels (known as serotonin selective re-
uptake inhibitors or SSRIs) as the combination of MAOIs and SSRIs can lead to higher levels of
serotonin in the body. SSRI medications generally require 6 weeks to clear the body and should
be reduced gradually.
If you are taking antibiotics or anti-depressants or receiving other medical treatment it is also
good practice to see your doctor and ask his or her advice about the effects of your medication in
combination with ayahuasca. There may be no problem but it is best to check.
Non-prescription medicines such as antihistamines, dietary aids, amphetamines and their
derivatives and some herbal remedies (e.g. those containing ephedrine, high levels of caffeine or
other stimulants) should be discontinued for at least a week prior to and following work with
ayahuasca. Please check with your herbalist or homeopath as even otherwise innocuous remedies
like St John’s Wort/hypericum may not be suitable in combination with ayahuasca.
Avoid all chemically-based recreational drugs, in particular MDMA (ecstasy), cocaine, speed
and heroin. Non-chemical recreational drugs such as marijuana should also be discontinued for a
period of at least two weeks prior to and following the program.
Ayahuasca and the diet that goes with it are not always ideal in combination with certain medical
conditions (e.g. some stomach, heart, colon or mental health problems, etc) so, again, please
check with your doctor and take his or her advice about participation.
The following information will be kept in the strictest confidence.
1. Are you taking any medications? Y N
If yes, which medications and for what condition/s.
edit this text
2. Have you sought health advice regarding these medications or conditions and your
participation in this event? Y N
If yes, are your advisors happy for you to take part? Y N
If no, are you happy to take part and to absolve us of responsibility and liability for any
abreactions? Y N
3. Do you have any physical or other limitations we should know about, especially some form
of heart condition? Y N
If yes please specify.
edit this text
4. Do you have any special needs we should know about – including allergies or dietary
requirements of a bona fide (not ‘fad diet’) medical nature? Y N
If yes please specify.
edit this text
5. Please provide us with a contact in case of emergency
Name: edit this text
Telephone: edit this text
Mobile/Cell phone: edit this text
Email: edit this text
TERMS AND CONDITIONS
I have read your terms and conditions and agree to abide by these. (Terms and conditions can
be found at the end of this brochure.)
TERMS AND CONDITIONS
Bookings are made on the understanding that you will abide by these terms and conditions.
“The Organizers” are James and Gina Davis of The Hummingbird Ayahuasca Retreat Center,
Peru and their agents, staff and assistants.
“The Participant" is the person named on the Booking Form for this event.
1. The Organizers reserve the right to accept or decline a Participant booking at any time.
2. The Participant agrees to take part in a program at The Hummingbird Retreat Center,
including its plant ceremonies.
3. The Organizers will do their utmost to ensure the safety and comfort of the Participant within
the remit of this program. The Participant, in turn, agrees to exercise caution and consideration
for him or herself and for others during this event, including at the venue and in other
environments, and indemnifies the Organisers against claims for injury, loss, damage,
misadventure or inconvenience at all stages.
4. The Participant has made confidential disclosures regarding medical conditions and/or use of
medications. The Organizers agree to keep these in confidence unless required by law to divulge
them and/or for the resolution of any dispute. The Participant agrees to inform the Organizers of
any change in circumstances.
5. The Organizers have recommended that the Participant, prior to entry into this Agreement, seeks and
obtains health or medical advice as to the effect of plants and herbal medicines singly and in
combination with any medication they are taking. The Participant avows that he or she, having done so
or deemed it unnecessary, is in a physical and mental condition appropriate to the activities described in
this brochure and agrees to participate at his or her own risk. The responsibility for taking accurate and
timely health precautions, professional medical advice, and for acting upon this (or otherwise) is solely
with the Participant.
6. The Participant has the option of joining any, all, or none of the activities on offer at The
Hummingbird Retreat Center and taking any, all or none of the plants available, and should he
or she wish to take them does so voluntarily, taking full responsibility for his or her actions.
7. The Participant has been advised that ayahuasca is a visionary plant and is clear on the meaning of
this. Reference sources have been provided which may describe the ayahuasca experience and the
Participant has conducted other research where appropriate to satisfy him or herself of the effects that
may be produced. The liability is with the Participant.
8. The Organisers agree to supply transportation, plant medicines, accommodation and food as
part of this event during the dates given and within the guidelines supplied (e.g. the ayahuasca
diet). The Organisers are not responsible for travel or other costs outside of this program or for
flight cancellations or other interruptions or travel disruptions and no refunds, reimbursements
or payments-in-kind will be made for these.
9. The Organisers reserve the right to make changes to the itinerary or costs of this program if necessary
or to cancel this event if need be. In the unlikely event that the program is cancelled a full refund will be
made to the Participant of fees paid by him or her to the Organisers. The Organisers are not, however,
responsible for other costs which the Participant may incur or have incurred such as transportation or
the purchase of any goods or materials.
10. The Organisers will do their best to help with any special requests or needs that the Participant may
make or have but are not beholden to do so and the Participant understands that such requests may
need to be paid for by the Participant separately to this program and its contents and that he or she may
also have to make his or her own arrangements (e.g. for travel outside the program) and at his or her
11. If the Participant withdraws from this event the program or retreat fee will be refunded in full
provided that his or her cancellation is made in writing and reaches the Organisers before 60 days prior
to the first day of the program, save for the Participant’s deposit which is non-refundable in all
circumstances. Other refunds will be made according to the table below. The Organisers are not
responsible for any other costs which the Participant may incur or have incurred.
Number of BEFORE 60 60-41 40-21 20-15 14-0
days the days days
cancellation is days days days
received in Including non-
writing by the attendance, ‘no
Organisers shows’ at our
prior to the meeting point or
program start leaving the program
date before its
Refund 100% 90% 60% 30% 0%
of the course of the of the of the of the course fee
fee minus course course fee course fee and deposit
deposit fee minus minus
minus deposit deposit
12. The Participant will not hold the Organisers liable for damages, injuries, losses, accidents or delays,
including wilful or negligent acts, failures to act or breaches of contract by any parties which supply
goods or services for this event.
13. The Participant indemnifies the Organisers against loss or damage, including that resulting from
insufficient or improperly issued passports, visas or other travel documents.
14. The Participant has been advised to take out suitable medical and travel insurance for their journey
and this event, covering personal accident, medical expenses, losses, repatriation costs and all other
expenses which might arise as a result of loss, damage, injury, delay or inconvenience. Group leaders
must also ensure that they have adequate public liability insurance to cover themselves and their group
in case of accidents or other misfortunes. The Organisers are not liable for such expenses.
15. The Participant - and his or her family – understand that the Amazon rainforest and this program
represent travel of a unique nature and will hold the Organisers and its associates, representatives and
employees blameless for any injury or ailment occurring during this program or afterwards. The onus is
on the Participant to explain this program to others if need be and to ensure their agreement and
16. The Participant agrees to show respect for the environment he or she is in and to act with courtesy
and dignity towards other group members and local and native people at The Hummingbird Retreat
Center and during external activities. Should the Participant commit any illegal act or should his or her
behaviour adversely affect other people’s enjoyment of this event he or she may be asked to leave the
Center and shall have no entitlement to complaint or refund and will bear any expenses as a result of
17. The Participant agrees that any photographs, videos, film or notes taken by the Organisers during
this event in which the Participant may feature may be published by the Organisers and gives consent to
this without consideration unless prior written agreements are entered into.
18. The Participant agrees to acknowledge The Hummingbird Ayahuasca Retreat Center and this
program (including email and website addresses) in any production of his or her own which may result
from his or her participation in this event, whether this is of a commercial or non-commercial nature.
This may include but is not limited to books, articles, films, videos, CDs, tapes, DVDs and productions
using on-line resources such as YouTube and Facebook which are intended or available for public
broadcast or diffusion. Such acknowledgement must not, however, be presented as an endorsement by
the Organisers of any materials produced by the Participant unless this is expressly agreed in writing.
19. The Participant acknowledges that the programs developed and promoted in this brochure,
including their contents, name, activities and the materials and information they have received about
them are the copyright, intellectual and trading property of The Hummingbird Retreat Center and/or Jim
Davis and Tracie Thornberry and agrees not to use these materials or information for any purpose which
is or may be construed as of a competitive nature, whether commercial (profit-seeking) or non-
commercial (‘humanitarian’ or not-for-profit) without the express permission of the Organisers given in
20. The relationship between the Participant and the Organisers is governed by Peruvian law and in the
unlikely event that a controversy arises which cannot be resolved between us both parties agree to the
exclusive jurisdiction of the Peruvian Courts in Iquitos, Peru.
21. The Participant has read, understood and voluntarily signed this document and agrees that no
representations, statements or inducements have been made by the Organisers for him/her to take part
in this program or to sign this Agreement. By signing the Participant waives certain legal rights, including
the right to sue.